Bacterial Meningitis

Topic Discussion: Ethan Robinson, Pharm.D.

March 12, 2024

Meningitis: inflammation of the meninges which are membranes that surround and
protect the brain and spinal cord

Diagnosis

Signs/Symptoms:

• Fever
• Headache
• Nuchal Rigidity
• Altered Mental Status
• Seizures (30% in children)
• Nausea/Vomiting
• Photophobia
• Rash (more common in meningococcal disease)

Blood Cultures (prior to abx)

CT Head:

• Imaging is NOT required prior to LP in most cases and may cause significant delays
in treatment.
• However, it should be performed if focal neurologic signs (rule out stroke),
uncontrolled seizures, Glasgow coma score ≤12, or papilledema (bilateral optic
disc swelling d/t elevated intracranial pressure [ICP]).
• Higher ICP increases the risk of brain herniation.
• May be necessary to delay LP in cases of septic shock, rapidly evolving rash, or
coagulopathies.
• This should NOT delay the administration of empiric antibiotics and steroids.
Lumbar Puncture:

• Cerebrospinal fluid (CSF) serology and culture

Normal Bacterial Viral TB Fungal

Opening 120 - 200 200 - 500 Normal Mixed Mixed
Pressure
(mm H2O)
Appearance Clear Cloudy Clear Mixed Mixed
WBCs <5 100 - 5000 5 - 1000 5 - 500 5 - 500
Cell Type n/a Neutrophils or Lymphocytes Lymphocytes Lymphocytes
Lymphocytes
(if Listeria or
prior abx)
Protein 15 - 60 Elevated Elevated Elevated Elevated
Glucose 50 – 80 < 40 Normal < 40 Low/Normal
CSF:Plasma 0.66 ≤ 0.4 (0.6 in ≤ 0.4 (0.6 in
Ratio neonates) neonates)

• 2% of patients with bacterial meningitis do NOT have CSF leukocytosis

(streptococcal meningitis or immunocompromised patients)
• CSF Gram-stain most commonly positive in pneumococcus, H. flu, and neisseria
• May also test for viral DNA/fungal antigens or lactate.

Additional labs:

• Serum CRP may be useful to rule out bacterial meningitis if gram stain is negative.
• Elevated serum procalcitonin is indicative of infection
Treatment

Empiric Antibiotic Therapy:

Cover for Strep pneumoniae and Neisseria meningitidis

• Ceftriaxone 2g q12h IV + IV vancomycin (target trough ~20 mcg/mL)

• Alternatives (if beta-lactam allergy) include moxifloxacin 400 mg IV q24h,
meropenem 2g q8h IV, rifampin 600 mg IV q24h, and IV chloramphenicol (rarely
used)

Ampicillin 3g q6h IV if patient ≥50 yo to cover Listeria monocytogenes

• Alternatives (if beta-lactam allergy) include meropenem 2g q8h IV or Bactrim 10-

20 mg/kg/day (of trimethoprim) IV in 2-4 divided doses

Role of Steroids:

• Dexamethasone 10 mg IV or 0.15 mg/kg IV q6h for 4 days

• First dose given 15-20 min prior to first antibiotic dose
• Reduces mortality and unfavorable outcomes in adults with meningitis and
pneumococcal meningitis
• Outcomes in children and neonates are mixed, but better evidence if given prior to
the first dose of abx
• Daptomycin is being investigated for use against meningitis-related inflammation
due to its inhibition of complement 5.

Duration of Therapy:

7 days (N. meningitidis, H. influenzae)

10-14 days (S. pneumoniae)

14-21 days (group B strep)

21 days (L. monocytogenes, gram negative rods)

Prognosis

Mortality is 10-20%

Long-term complications:

• Hearing loss
• Vision loss
• Memory loss
• Seizures
• Limb weakness/paralysis
• Speech/language difficulties

References

Carter E, McGill F. The management of acute meningitis: an update. Clin Med (Lond).
2022;22(5):396-400. doi:10.7861/clinmed.2022-cme-meningitis

Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of
bacterial meningitis. Clin Infect Dis. 2004;39(9):1267-1284. doi:10.1086/425368